Late referrals to home palliative care service affecting death at home in advanced cancer patients in Japan: a nationwide survey.

BACKGROUND: To identify factors influencing place of death among home palliative care patients with advanced cancer, focusing on the timing of referrals from hospital to home care settings. METHODS: A cross-sectional nationwide questionnaire survey was conducted on home palliative care patients at 1000 randomly selected home care agencies in Japan. A total of 568 responses were analyzed (effective response rate, 69%). RESULTS: Multivariate logistic regression analysis revealed that (i) predischarge health care supports in hospital (e.g. early referral 8 days or more before discharge; clear explanation by hospital staffs to patients and families regarding discharge to live and die at home) and (ii) postdischarge health care supports after transferring home care (e.g. signing a 24-h support insurance contract of network between primary physician and nurse as a home palliative care team; primary nurse consultation with primary physician >3 times during the first week after discharge) have an effect on place of death among home palliative care patients. CONCLUSION: An early and carefully coordinated referral support system for smooth discharge by hospital staffs as well as intensive and highly qualified support just after discharge by the home care team would help to increase the number of patients who could die at home.

Stratum corneum TARC level is a new indicator of lesional skin inflammation in atopic dermatitis.

BACKGROUND: Management of atopic dermatitis (AD) requires judging the symptoms of local skin lesions and prescribing a suitable treatment. However, no method has been established in which objective measures can be used to evaluate the severity of local symptoms. We established a method for measuring thymus and activation-regulated chemokine (TARC) levels in the stratum corneum (scTARC), and examined whether the scTARC can be used as an indicator of the severity of local skin lesions in patients with AD. METHODS: Stratum corneum was obtained from patients with AD by tape-stripping, and scTARC was evaluated using a TARC-specific antibody followed by image analysis. The scTARC was examined to determine correlation with the severity of local skin lesions (the severity of erythema, edema/papule, oozing/crusts, excoriations, lichenification, and xerosis) as well as with the severity scoring of atopic dermatitis (SCORAD) index, serum TARC level, serum IgE level, serum lactate dehydrogenase (LDH) level, interleukin (IL)-4-producing T cell ratio (Th2 cell ratio), and blood eosinophil count. RESULTS: The scTARC was correlated with the severity of local skin lesions, especially with the erythema, edema/papule, and oozing/crusts score. The scTARC in the most severe lesions was also correlated with the SCORAD index, serum TARC level, serum IgE level, and blood eosinophil count. The scTARC was not, however, correlated with the serum LDH level and Th2 cell ratio. CONCLUSION: An immunofluorescent technique combined with tape-stripping was used to measure scTARC. The scTARC can be used as an indicator of the severity of local acute inflammation in patients with AD.

Prevention of amputation caused by rheumatic diseases following a novel therapy of exposing bone marrow, occlusive dressing and subsequent epidermal grafting.

BACKGROUND: Wounds with exposed bones caused by rheumatic diseases commonly result in amputation despite progress in our understanding of wound-healing mechanisms. OBJECTIVES: To determine whether an experimental therapy of bone marrow exposure, an occlusive dressing and subsequent grafting of epidermal sheets accelerates healing and reduces the need for amputation in patients with rheumatic diseases. METHODS: Fifteen patients, including those with rheumatoid arthritis or systemic sclerosis, who had wounds with exposed bones were treated either with the standard procedure, consisting of local wound care, debridement with a scalpel, bed rest and parenteral antibiotics (n = 8), or with a newly developed experimental procedure (n = 7). In that new procedure, the affected bone was initially exposed by debridement with a scalpel, followed by partial excision with a bone scraper until bleeding was observed from the exposed bone. The lesions were immediately covered with an occlusive dressing, and were eventually treated with epidermal grafts obtained from suction blisters. RESULTS: A comparison with standard therapy demonstrated that the time needed for wound healing was similar, but that the newly developed combination therapy reduced the risk of amputation (P = 0.020). No skin ulcers or erosions were observed for at least 1 year in five of seven patients (72%) due to the adoption of stable palmoplantar-type characteristics in grafts derived from the trunk epidermis. CONCLUSIONS: Our study indicates that exposure of bone marrow cells plus an occlusive dressing accelerates the healing of skin ulcers at least partly through the preparation of a healthy well-granulated wound bed and that subsequent epidermal grafting achieves site-specific differentiation through epithelial-mesenchymal interactions.

Rapid healing of intractable diabetic foot ulcers with exposed bones following a novel therapy of exposing bone marrow cells and then grafting epidermal sheets.

BACKGROUND: Diabetic foot ulcers with exposed bones commonly result in amputation. OBJECTIVES: To determine whether exposure of bone marrow cells and subsequent grafting of epidermal sheets accelerates healing and reduces the need for amputation. METHODS: Thirty-eight patients with chronic wounds caused by diabetes mellitus were enrolled in this study. Epidermal sheets obtained from suction blisters of each patient were grafted on to diabetic foot ulcers without exposed bones (n = 10) and were compared with the standard treatment of local wound care, debridement with a scalpel when indicated, bed rest and parenteral antibiotics (n = 8). In another group of patients, diabetic wounds with exposed bones were treated either with the standard procedure (n = 9) or with a newly developed experimental procedure (n = 11). In that new procedure, the affected bone was initially exposed by debridement with a scalpel, followed by partial excision with a bone scraper until fresh bleeding was observed from the exposed bone. The lesions were then immediately covered with an occlusive dressing, and finally the wound was covered with an epidermal graft of skin harvested from suction blisters. Patients in each group were matched with their counterparts by age, sex, wound size, wound infection and wound duration, to compare the time needed for total skin repair and rates of amputation. RESULTS: Epidermal grafting significantly accelerated the healing of diabetic foot ulcers (P = 0.042) without exposed bones, with site-specific differentiation. The newly developed combination therapy resulted in the healing of all diabetic ulcers with exposed bones without the occurrence of osteomyelitis or the necessity for amputation (P < 0.0001). CONCLUSIONS: Our study indicates that early aggressive debridement of diabetic foot ulcers with exposed bones down to a bleeding vascularized base and then grafting epidermal sheets significantly improves healing and reduces the rate of amputation.

Contribution of hydrogen bonds to the conformational stability of human lysozyme: calorimetry and X-ray analysis of six tyrosine --> phenylalanine mutants.

The contribution of hydrogen bonds to the conformational stability of human lysozyme was investigated by the combination of calorimetric and X-ray analyses of six Tyr --> Phe mutants. Unfolding Delta G and unfolding Delta H values of the Tyr --> Phe mutant proteins were changed by from +0.3 to -4.0 kJ/mol and from 0 to -16 kJ/mol, respectively, compared to those of the wild-type protein. The net contribution of a hydrogen bond at a specific site to stability (Delta Gwild/HB), considering factors affected by substitutions, was evaluated on the basis of X-ray structures of the mutant proteins. In the present study, one of six mutant proteins was suitable for evaluating the strength of the hydrogen bond. Delta Gwild/HB for the intramolecular hydrogen bond at Tyr124 was evaluated to be 7.5 kJ/mol. Results of the analysis of other mutants also suggest that hydrogen bonds of the hydroxyl group of Tyr, including the hydrogen bond with a water molecule, contribute to the stabilization of the human lysozyme.

Estimation of the gonial angle from the orthopantomogram.

We set a new basic plane on an orthopantomogram in order to measure the gonial angle and obtained the following: 1) Usable error difference in ordinary clinical setting ranged from 0.5 degrees-1.0 degree. 2) Because there is no great difference between the levels of the gonial on orthopantomograms, they are effective for investigation of the changes of side and degree. Thus, based on the above results, 100 cases were randomly selected from the Angle class III cases which were treated at our department of orthodontics in order to investigate the differences between the left and the right side and pre and post-treatment changes and obtained the following results: 1) Pretreatment differences between the right and the left sides were recognized in 88 cases. 2) 66 cases showed posttreatment improvement in the differences between both sides. Because orthopantomograms are applied at the end of treatment and for evaluation of the stability of occlusion. We will investigate if the occlusion is best harmonized at equal gonial angles on both sides, using a combination of EMG and measurement of occlusion force, and will also study various cases in more detail.

[Rapid compression of maxillary molar region, and its effects on sutures of the cranio-facial bones].

Twenty young hybrid dogs were classified into 5 groups: the control, the group examined immediately after 2 weeks compression (3.52 mm), and those examined at 2, 4 and 8 weeks retention. In those animals undergoing compression 4 times, Dentaurum expansion screws (#602-813) were placed between the left and right fourth dento premolar. when rapid compression was used interruptedly, local synostosis was only seen in the palatine suture, but following retention for 8 weeks, this phenomenon almost completely disappeared. The internal mechanical force of the adjoining sutures had disappeared within 4 weeks of retention. In conclusion, this clinical application causes no permanent damage.